CHAPTER 69 PRINCIPLES OF PLASTIC SURGERY AFTER MASSIVE WEIGHT LOSS
J. PETER RUBIN
Plastic surgery following massive weight loss (MWL) is a relatively new subspecialty of plastic surgery, fueled by the obesity epidemic and successful outcomes from bariatric surgery. MWL patients represent a unique cohort that differs from typical body contouring patients. Evaluation must take into account complex medical and psychosocial issues associated with obesity and operative planning requires unique strategies. The goal of this chapter is to provide a safe and comprehensive approach to management of the MWL patient. Technical details of specific operative procedures appear inChapters 65 to 68. The key topics covered here are 1) the medical impact of obesity and the rise of bariatric surgery as an effective therapy, 2) critical factors for consideration in the preoperative evaluation of the MWL patient presenting for plastic surgery, and 3) a framework for designing a safe operative plan, including when to combine multiple procedures and when to perform them in separate stages.
OBESITY, ASSOCIATED MEDICAL COMORBIDITIES, AND IMPACT OF BARIATRIC SURGERY
Obesity has a major impact on the health of our patients, and an appreciation for the medical problems associated with overweight and obese patients is vital. The key metric, body mass index (BMI), obtained by dividing weight in kilograms by height in meters squared (kg/m2), is used to define “overweight” as a BMI of 25.0 to 29.9 kg/m,2 obesity as a BMI > 30 kg/m2, severe obesity as a BMI > 35 kg/m2, and morbid obesity as a BMI > 40 kg/m2. Obesity rates in the United States, based on 2010 Centers for Disease Control data, reveal that no state has a prevalence of obesity less than 20%. In contrast, 1995 data indicated not a single US state had an obesity prevalence rate exceeding 20%.1 A striking statistic is that 33.8% of adults over age 20 are classified as obese, and nearly 5% are morbidly obese with a BMI > 40 kg/m2.2 Worldwide, the International Obesity Task Force estimates that over 1 billion individuals are overweight and 475 million are obese.3
Medical comorbid conditions associated with obesity are numerous. Diabetes, hyperlipidemia, hypertension, obstructive sleep apnea (OSA), gastroesophageal reflux disease, and osteoarthritis are common. These conditions are all greatly improved by weight loss, but may still be present at the time of plastic surgery consultation and are specifically considered and addressed.
The most effective treatment for morbid obesity is bariatric surgery, and a 1991 National Institutes of Health Consensus Conference recommended the procedure for patients with a BMI > 40 kg/m2 or a BMI > 35 kg/m2 with significant comorbid conditions.4
Since that time, rates of bariatric procedures performed have increased steadily, with over 200,000 people undergoing various weight loss procedures annually. The improvement of obesity-related medical disorders following bariatric surgery has been a major health benefit.5,6
Deflation of the skin envelope after successful weight loss results in a varied constellation of deformities in many bariatric surgery patients. Nearly every region of the body can be affected, resulting in redundant, loose, hanging rolls of skin and fat often in patterns that had not previously been described in the plastic surgery literature.7 These deformities lead to intertriginous rashes, chronic fungal infections, skin breakdown, soft tissue sepsis, and social embarrassment. Patients frequently seek consultation with a plastic surgeon to address these deformities, and often consider body contouring as the “final phase of their weight loss journey.” With the increased number of bariatric procedures, body contouring has been a tremendous area of growth in plastic surgery, and many plastic surgeons are now exposed to the weight loss population in their training and practices.8
The surgeon must bear in mind that these are truly elective cases on complex patients and deferring surgery to modify risk factors is never a bad option. Indeed, in the Life After Weight Loss post-bariatric center at the University of Pittsburgh, patients are often engaged in a collaborative effort to further reduce BMI or improve nutritional status over a period of many months before surgery is offered.9
We have identified six key assessment points in a comprehensive preoperative evaluation of the MWL patient: 1) timing of body contouring surgery relative to gastric bypass; 2) BMI at presentation; 3) nutritional assessment; 4) evaluation for medical comorbidities of obesity; 5) evaluation of psychosocial issues, and 6) assessment of the physical deformities. Table 69.1 outlines pitfalls at each step, along with pitfalls in operative planning and management.
The surgeon and office staff must recognize that an MWL patient has made a major life transformation through great dedication and should be congratulated on this accomplishment. Importantly, since these patients are constantly struggling with self-esteem issues, appropriate compassion helps them feel more comfortable.
Weight Loss History and Timing of Plastic Surgery Relative to Bariatric Surgery
A history of the age of onset of obesity, family history of obesity, and course of obesity over the patient’s life leading up to bariatric surgery is obtained. A detailed history of the type of bariatric procedure performed includes the type of procedure, date of procedure, any complications and/or additional procedures, and course of weight loss since the procedure. An accurate weight is obtained in the office, and inquiry made about goal weight. The highest BMI prior to bariatric surgery, the lowest BMI since bariatric surgery, and the BMI at the time of presentation are calculated and recorded. Additionally, we find it helpful to document weight loss over the previous month and 3 months prior to presentation. We require weight stability, defined by not more than 5 lb of weight change per month in the previous 3 months.
Timing of plastic surgery following MWL is an important factor and patients must be at a stable weight before undergoing body contouring. Patients typically experience a significant and rapid weight loss during the first year after bariatric surgery. In general, a minimum of 12 months should elapse following weight loss surgery to enable the patient to reach this plateau, and often a plateau is not observed until 18 months post-op. A patient still undergoing rapid weight loss may not have achieved metabolic and nutritional homeostasis and could be at risk for suboptimal wound healing.Protein intake is usually improved for patients after 12 months following bariatric surgery. In addition, the aesthetic results may be compromised if a patient loses a significant amount of weight after body contouring surgery. Patients still actively losing weight are deferred and reassessed in 3 months.10
Role of BMI
Once weight stability is verified, BMI at presentation is carefully considered. There is no absolute threshold for BMI prior to surgery, but the best candidates for extensive body contouring surgery typically have a BMI less than 30 kg/m2 and can be considered for a wide range of procedures including multiple procedures, if their medical and psychological conditions are favorable.12 While a BMI lower than 25 kg/m2 is optimal, that value is not commonly seen after MWL and many successful bariatric patients will present in the BMI range of 25 to 30 kg/m2. At higher BMIs between 30 and 35 kg/m2, one must be more selective and evaluate individual patterns of body fat distribution to guide surgical planning. For example, a patient with an android body type might have a large intra-abdominal adipose burden at a BMI of 35 kg/m2 that limits effective abdominal contouring. Patients with a BMI between 35 and 40 kg/m2 tend to have findings that limit effective aesthetic contouring, including a thicker subcutaneous adipose layer and a large intra-abdominal fat compartment. In this patient group, we focus on single procedure, functional operations to relieve symptoms and encourage further weight loss. An initial panniculectomy or reduction mammaplasty can greatly improve comfort and ability to exercise as the patient strives for further weight loss. Surgery is usually deferred for patients with a BMI > 40 kg/m2 until they achieve further weight loss, unless symptoms are unusually severe (e.g., acute or recurrent soft tissue sepsis on the pannus).
When a patient with a higher than optimal BMI is encountered, the surgeon should consider deferring surgery and referring the patient back to the bariatric surgeon and/or nutritionist for further weight loss. Follow-up visits with the plastic surgeon at 3-month intervals will keep the patients engaged and motivated toward their goals of being good candidates for body contouring surgery.
Regarding risk and BMI, a prospective analysis of 511 post-bariatric cases at our center demonstrated that both higher pre-bariatric maximum BMI and BMI at presentation were associated with increased complications in patients undergoing a single body contouring procedure. The same study found that the change in BMI (maximum to BMI at presentation) was directly related to overall complications in patients undergoing multiple procedures.11 These BMI parameters and their association with complications have been corroborated by other investigations.12 Others have found that the frequency of both major and minor complications were higher in the morbidly obese and severely morbidly obese groups.13
Search for Residual Medical Comorbidities
Weight loss induced by bariatric surgery improves health and alleviates active disease, with effects noted often within the first 2 to 5 months postoperatively.14 It is gratifying to hear patients talk about going from handful of medications to barely any prescription drugs. However, the plastic surgeon must actively inquire about the most common comorbidities of obesity and search for unresolved issues.While Pories et al.15 demonstrated that 82% of obese patients with type II diabetes mellitus had resolution of their disease following weight loss, patients with persistent insulin resistance will still present to the plastic surgeon. Hemoglobin A1C is checked as an indicator of glucose control. Oral hypoglycemic agents are held on the morning of surgery, and insulin dose, if applicable, is reduced on the morning of surgery consistent with the fasting state. For all diabetic patients, glucose is monitored every 6 hours postoperatively and treated with an insulin sliding scale for tight glycemic control. The plastic surgeon may opt for assistance from an internist in the management of these issues but the ultimate responsibility is his/hers and the surgeon should be familiar with the dose of every medication given to his/her patient.
Obstructive sleep apnea (OSA) is another common comorbidity of obesity and may still be present in patients presenting for plastic surgery. Risks and complications associated with OSA include myocardial infarction, stroke, arrhythmia, and sudden death. Patients should be questioned about recent sleep studies and recommendations for perioperative management obtained from the treating pulmonologist or internist. If patients use continuous positive airway pressure (CPAP) devices at home, they should be instructed to bring their own CPAP machine and mask for use after surgery, as their device will be well tolerated and will increase compliance during the inpatient stay.
Hypertension is highly prevalent in the obese population, and bariatric surgery is very effective at reducing hypertension, with 50% to 60% of patients becoming normotensive.16,17 It is, however, imperative to question the patient about symptoms of active cardiovascular disease during the interview, including exertional dyspnea and chest pain. Inactive patients, especially in higher age ranges, raise concern for underlying cardiac disease that could be unmasked by the stress of a major surgical procedure. Exercise tolerance is a useful topic to explore during the interview, as patients who routinely tolerate 45 minutes of vigorous exercise are likely to tolerate the stress of surgery (Chapter 11). Given the magnitude of major body contouring procedures, we are quick to refer patients for a preoperative stress test and other appropriate cardiovascular studies.
Risk factors for venous thromboembolism (VTE) are assessed, including current obesity state, immobility, increasing age, and venous varicosities.18 Additionally, the potential for hereditary coagulopathies is considered. A history of multiple spontaneous abortions, in particular, should arouse suspicion of an underlying thrombophilia.19 Moreover, all patients with a documented history of VTE are tested for hypercoagulable disorders and referred where indicated to a hematologist for perioperative risk assessment and recommendations. For particularly high-risk patients, placement of a temporary inferior vena cava filter is considered. Shermak and colleagues investigated the incidence of VTE in the post-bariatric body contouring population. They showed an overall risk for VTE of 2.9% for all patients undergoing body contouring surgery. This rate increased to 8.9% for patients with a BMI of 35 kg/m2 or greater.20 While clear evidence-based guidelines for the use of chemoprophylaxis have not been established for plastic surgery, all patients should have intermittent pneumatic compression devices applied prior to the induction of general anesthesia. Early ambulation is critical and must be stressed during hospitalization and at the time of discharge.
Risk of platelet dysfunction from medications, including aspirin and nonsteroidal anti-inflammatory agents, is considered, especially given the prevalence of osteoarthritis in this population, and the medications are discontinued for at least 2 weeks before surgery. Inquiries are also made about herbal medications and these agents held preoperatively.
Tobacco use is another modifiable risk factor for postoperative complications. In our center, we are aggressive about educating patients and hopefully getting them to partner in optimizing their own outcomes by ceasing their smoking habit. Often, a surgery date is not scheduled until the patient has stopped tobacco use.
One other factor to consider is a potential higher risk of perioperative pulmonary aspiration in patients with a gastric band. It is advisable to consult with the patient’s bariatric surgeon to see if they advise deflating the band prior to plastic surgery.
Nutritional evaluation begins with an inquiry about persistent nausea and vomiting. These symptoms could suggest a mechanical stricture necessitating referral to the bariatric surgeon. Nausea and vomiting also raises suspicion for thiamine deficiency (see below). Inquiries are also made about symptoms of dumping, which, when present, raise particular concern for protein malnutrition.21
The type of weight loss procedure that the patient underwent is also relevant. Purely restrictive operations, such as gastric banding and vertical banded gastroplasty, have a low risk of nutritional deficiencies. Roux-en-Y gastric bypass, a common bariatric procedure performed in the United States, is both restrictive and malabsorptive and is associated with a higher incidence of nutritional deficiencies compared with restrictive procedures. The plastic surgeon must be aware of older malabsorptive procedures such as the duodenal switch and biliopancreatic diversion, as these have the highest risk of nutritional derangements.
Protein intake is a key factor for the post-bariatric patient. Food aversions and difficulty tolerating red meat and other animal protein sources are often noted after gastric bypass. This may not be a problem in the unstressed state, but major elective surgery will require an increased calorie and protein consumption of up to 25%.22 A formal interview and assessment by a nutritionist is helpful to obtain an estimation of daily protein intake. Even without the use of a nutritionist, however, the plastic surgeon can certainly get a rough estimate of a patient’s daily protein intake by having the patient list the foods consumed during the previous 2 days and calculating nutrient value from standard food composition tables. A good source is the online U.S. Department of Agriculture Food and Nutrient Database for Dietary Studies 4.1., http://www.ars.usda.gov/Services/docs.htm?docid=12089.23 Patients are counseled on how to read food package labels and advised to increase their daily protein intake to at least 70 to 100 gm/day and focus on lean, protein rich foods. This may require specific protein supplements, such as whey sources, that they are able to tolerate. The challenge is identifying protein sources that are low in fat and carbohydrate content. Gastric bypass patients may have a high daily protein intake and still be at risk for protein malnutrition. In our prospective study of gastric bypass patients, we found a 13.8% incidence of low albumin and a 6.5% incidence of low prealbumin, with no correlation found between measured serum protein levels and reported daily protein intake. Therefore, protein malnutrition cannot be effectively ruled out by history alone in the post-bariatric patient and serum protein measures should be obtained in the preoperative workup.21
A host of micronutrient deficiencies are also seen in this patient population.24-26 Iron deficiency is common, especially in women, and is frequently associated with anemia27 requiring treatment with daily iron supplements. In the author’s prospective evaluation of patients presenting for plastic surgery after weight loss, iron deficiency was the most common nutritional derangement with an incidence of 39.7%.21
Calcium deficiencies are observed after malabsorptive procedures, and supplementation with 1,200 to 1,500 mg of calcium citrate daily is employed. Vitamin B12 deficiency may be present and is supplemented with 500 to 600 µg daily to avoid megaloblastic anemia and potential peripheral neuropathy. Folate deficiency is less commonly seen, but may also result in megaloblastic anemia.24-26Thiamine deficiency may be encountered and symptoms can be potentiated during surgery by intravenous solutions containing dextrose. If postoperative neurological symptoms are noted, thiamine is likely deficient and if left untreated may result in Wernicke-Korsakoff encephalopathy, progressive paralysis, coma, and even death. We have had occasion to observe this phenomenon in our center and fortunately the neurologic symptoms were reversed with intravenous thiamine, starting with an initial bolus of 100 mg.28
PSYCHOLOGICAL CONSIDERATIONS AND MANAGING PATIENT EXPECTATIONS
Body image issues and low self-esteem are prevalent in the bariatric population even after successful weight loss, and abundant, excess, loose-hanging skin may be one cause.24 Beyond the loose skin, however, many bariatric patients describe difficulty shedding their former body image even after weight loss and describe seeing themselves as still being “obese.” The psychological issues are complex, and the risk of major depression is nearly five times higher in individuals with a BMI > 40 kg/m2 when compared with individuals of average weight.29 Unlike diabetes and hypertension, which often disappear after weight loss, the mood and personality disorders, destructive eating patterns, and poor body image issues seen in obese patients often do not resolve.30-32 The common finding of controlled depression in the weight loss patient is not, in itself, a contraindication to body contouring surgery. However, patients with a diagnosis of bipolar disorder or schizophrenia require an evaluation and clearance from their mental health provider before body contouring surgery.33
A supportive social network is vital during the recovery period from major body contouring procedures. First of all, MWL itself may drastically alter a patient’s interpersonal relationship. Some relationships may be strengthened but many patients report separations, divorces, and new relationships. Before undertaking major procedures, the plastic surgeon should make sure adequate support systems are in place.
Setting expectations begins with an understanding of motivations and priorities. The patient must identify the anatomic regions of greatest concern to them. Most patients have a positive tone, express pride in their accomplishments, and articulate what they expect from the body contouring operation. Patients must accept the scars and significant recovery period, and embrace the concept that they will be significantly improved but not “perfect.”
Even with a good outcome, patients tend to forget their preoperative appearance. Occasional review of the preoperative photos during postoperative visits helps remind the patients how far they have progressed and keeps them motivated.34
Despite the fact that MWL patients have significant deformities, they can still have body dysmorphic disorder or similar severe body image derangements that preclude satisfactory outcome. This is a serious pitfall. During the consultation, it is vital to observe the patient’s affect and mood while they describe their lifestyle and the impact of the hanging skin. Patients who are morose, overly preoccupied with their deformities, and spend an inordinate amount of time thinking about their loose skin (especially if these thoughts are highly disruptive) are likely poor candidates. Importantly, patients who inappropriately attribute problems with job performance, career advancement, relationships, and general self-esteem to the loose skin are to be avoided. When patients are scar-averse and use terms such as “normal” for the expected outcome, the surgeon is wise to defer intervention. In such circumstances, it is nearly impossible to meet expectations no matter how skillfully the surgery is performed. Those individuals who express unrealistic expectations or questionable motivations for undertaking body contouring procedures are much more likely to be disappointed or dissatisfied; surgery should be deferred pending a psychiatric evaluation.32-34
Evaluating the Anatomic Deformities
The MWL patient is unique in that nearly every part of the body can be affected. A thorough evaluation considers not just the loose skin, but relative body type (android versus gynoid), overall body fat distribution, skin tone in different regions, skin folds/rolls, and regional adiposity. The locations of tethering points that define a skin roll are noted, as well as the presence of multiple rolls. The Pittsburgh Rating Scale is a point-based rating system for severity of deformities in the MWL patient by anatomic region7 and correlates severity to the type of treatment. Challenging cases require that both loose skin and excess adipose deposits are addressed, and this may entail a combination of excisional surgery and liposuction. Additionally, an important surgical concept is that not all excess adipose tissue is best treated by excision; some adipose tissue can be transposed to a new location adding volume and shape to the breast or buttock region.
Special Considerations in Preoperative Counseling
Most MWL patients, with proper counseling, are very satisfied with their surgery. Important concepts to emphasize are scarring, lack of effect on regions outside those being treated, potential for recurrence of skin laxity, magnitude of recovery, and risk of wound healing complications.10 It is essential that the patient recognize the trade-off between removing excess skin accepting scars. For MWL surgery, the phrase holds true that “minimal access scars equals minimal results.” It is often useful to draw the anticipated scar position on the patient with a marker in front of a full-length mirror. These marks can also be photographed to document the discussion. The best way to simulate the effect of surgery during the consultation is by pinching together the tissues to be manipulated and demonstrating the pull on the adjacent tissues. Just as important as explaining what the operation will accomplish is describing what the operation will not do. Patients often have the misperception that an operation, such as an abdominoplasty, with correct upper back rolls or buttock ptosis through tissue pull. The surgeon must explain where the impact of a given operation ends anatomically. Another important concept to communicate is that recurrent skin laxity may occur after body contouring, no matter how tight the tissues are pulled in the operating room and that recurrent laxity may warrant surgical revision.33 Patients must be properly informed about the magnitude of recovery. Given the popularity of laparoscopic bariatric surgery, patients should be educated that body contouring procedures are much more invasive and not “simple skin tucks.” Patients must also understand the high incidence of wound healing complications in MWL body contouring procedures, including wound dehiscence and seroma.35
COMBINING AND STAGING PROCEDURES
Patients will often present with multiple regions of concern and satisfaction will be maximized if these areas are addressed in order of priority. Certain procedures can be combined in a single operative procedure (Table 69.2). The decision to perform multiple procedures takes into consideration the medical condition of the patient, the composition of the operative team, the surgeon’s experience with body contouring surgery, the facility in which these procedures are performed, and financial burden for the patient (Table 69.3). Single procedures and combinations of procedures can be organized into a staged plan. Reducing concurrent procedures and opting for staging is always the default plan in higher risk cases. Table 69.4 shows the relative advantages and disadvantages of combining and staging procedures. A clear advantage of a staged approach is that it provides a planned opportunity to revise recurrent skin laxity after previous procedures. We prefer a minimum of 3 months between stages with no firm upper limit on intraoperative time for each operative episode.35 We attempt to avoid combining procedures that would result in opposing vectors of tension. In our practice, most patients requesting total body reshaping will require a minimum of two stages, not including facial rejuvenation. Figure 69.1 shows an example of a staged approach to total body reshaping in which the circumferential lower body lift, the cornerstone operation for lower trunk contouring (Chapters 66 and 67), is combined with one upper body procedure (brachioplasty) (Chapter 68) in the first stage. The vertical thigh lift (Chapter 67) and a second upper body procedure (transverse upper body lift and mastopexy) are performed in the second stage. This plan avoids the simultaneous opposing vectors of tension from the upper and lower body lift, separates the vertical thigh lift from the circumferential lower body lift, and avoids a fresh “T” point at the junction between the chest extension of the brachioplasty scar and the upper body lift. As previously reported, combining body contouring procedures is safe in well-selected patients. Aggregate minor complication rates are higher than in single-stage cases, but there is no increase in complications on a per-procedure basis (i.e., the total complication rate is the sum of the expected complication rate for each individual procedure).36 To maintain patient safety during multiple procedures, fluid balance, blood loss, and body temperature are carefully monitored during the procedure. The patient is advised preoperatively that the surgeon will truncate the operation if there is evidence of increased risk.
FIGURE 69.1. A 38-year-old woman desired total body contouring after a weight loss of 209 lb. A–C. Preoperative views. D–F. Postoperative views 5 months after stage 1, consisting of fleur-de-lis abdominoplasty, lateral thigh/buttock lift, and brachioplasty. G–I. Postoperative views 9 months after stage 2, consisting of dermal suspension and parenchymal reshaping mastopexy, upper back lift, and vertical medial thigh lift. Reprinted, with permission, from Coon D, Michaels J, Gusenoff JA, Purnell C, Friedman T, Rubin JP. Multiple procedures and staging in the massive weight loss population. Plast Reconstr Surg. 2010;125(2):691-698.
Plastic surgery after MWL has a tremendously positive impact on the lives of many patients. With the worldwide increase in obesity rates and success of bariatric surgery, plastic surgeons will continue to encounter MWL patients requesting body contouring procedures. A methodical approach and careful operative planning maximizes patient safety and outcomes.
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36. Coon D, Michaels J, Gusenoff J, et al. Multiple procedures and staging in the massive weight loss population. Plast Reconstr Surg. 2010;125: 691-698.